HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 36 PATTON LANE 11/28/2025 Commonwealth of Massachusetts Andover
w City/Town of No.Andover
DEC System Pumping Record 025
Form 4
DEP has provided this form for use by local Boards of Health, other worms may be use
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15,351.
A. Facility Information
Important:when
filling out forms 1. System Location , --
on the computer, o
use only the tab _ -. %' c'' .
key to move your Address
cursor-do not
use the return —-------------. ____. _...-_
key. City/Town State Zip Code
r�
2. System owner:
__. - ...
Name
ranan
Address(if different f;gym location)
No.Andover MA
Cify Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ...L 2. Quantity Pumped: .. ......_.. -- -
� Gallons
3. Component: ] Cesspool(s) /Septic Tank Tight Tank Grease Trap
Other (describe): - _ _ - ...
4. Effluent Tee Filter, present? ] Yes No If yes, was it cleaned? j Yes _ No
5. observed condition ofcomponent pumped:
6. System 0 ump1�,
By: ~
q,r
-------- 1- - b.-I I- ---- --1--l-111111-11--- ---------
Name Vehicle License Number
Stewart's S tic 53 So Kimball St.. , Bradford_,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler pate
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12
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